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SWORN STATEMENT UNDER SECTION 105.08, INDIAN RIVER
<br />COUNTY CODE, ON DISCLOSURE OF RELATIONSHIPS
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
<br />OFFICER AUTHORIZED TO ADMINISTER OATHS,
<br />1. This sworn statement is submitted with Bid, Proposal or Contract No. 2006060 for
<br />Oslo Road Clearing, 8th Court SW to 27th Avenue SW
<br />2. This sworn statement is submitted by: P- J. 's Land Clearing & Excavating, Inc.
<br />name of entity submitting Statement)
<br />3. whose business address is: P.O. Box 540517, Greenacres, F1. 33454
<br />and (if applicable) its Federal Employer Identification Number (FEIN) is 65-0896310 (If the
<br />entity has no FEIN, include the Social Security Number of the individual signing this sworn
<br />statement )
<br />My name is Patrick Wilson
<br />(Please print name of individual signing)
<br />and my relationship to the entity named above is President / owner
<br />4. I understand that an "affiliate" as defined in Section 105.08, Indian River County Code, means:
<br />The term "affiliate" includes those officers, directors, executives, partners, shareholders,
<br />employees, members, and agents who are active in the management of the entity.
<br />5. I understand that the relationship with a County Commissioner or County employee that must be
<br />disclosed as follows:
<br />Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, husband,
<br />wife, father-in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law, sister-in-law,
<br />stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister,
<br />grandparent, or grandchild.
<br />6. Based on information and belief, the statement, which I have marked below, is true in relation to
<br />the entity submitting this sworn statement. [Please indicate which statement applies.]
<br />XX Neither the entity submitting this sworn statement, nor any officers, directors, executives,
<br />partners, shareholders, employees, members, or agents who are active in management of the
<br />entity, have any relationships as defined in section 105.08, Indian River County Code, with any
<br />County Commissioner or County employee.
<br />The entity submitting this sworn statement, or one or more of the officers, directors,
<br />executives, partners, shareholders, employees, members, or agents, who are active in management
<br />of the entity have the following relationships with a County Commissioner or County employee:
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